Trauma-Focused

Cognitive Behavioral
Therapy
2-Day Training

Ashley Labistour, LMFT

TF-CBT National Trainer
Independent Consultant, Carpinteria , CA

Trauma-Focused CBT
Judy Cohen, M.D. & Tony Mannarino, Ph.D.
Allegheny General Hospital
Esther Deblinger, Ph.D.
New Jersey CARES Institute

What is TF-CBT?
A hybrid treatment model that

integrates:

Trauma sensitive interventions

Cognitive-behavioral principles
Attachment theory
Developmental neurobiology theory
Elements of family, humanistic and
empowerment theories

TF-CBT Goals
Resolve PTSD, depressive,

anxiety and other traumarelated symptoms in children

Optimize adaptive functioning
Enhance safety, family

communication and future

developmental trajectory

ft each client/family

Interventions tailored to

optimal, siblings may

be included as clinically
appropriate

Parental involvement is

model

Gradual exposure

will be determined by
each client and familys
needs (generally around
12-18 sessions)

Intensity and duration

based model

Interrelated component-

TF-CBT parameters

When do I use TF-CBT?

Target symptoms: PTSD, depression, anxiety,

and behavioral symptoms secondary to trauma.

Children presenting with predominance of

behavioral problems may beneft from a

different treatment.

TF-CBT has been used for all types of traumas

TF-CBT has been used for children ages 3-18,

with and without parental participation, in

schools, group homes, foster homes and inhome settings.

TF-CBT benefts
Course of treatment is brief, symptom

reduction rapid
Improvement in parent-child

interactions: increased communication,

closeness
Flexibility and Creativity
Evidence-based: Currently about 18

studies supporting the efficacy of TFCBT

TF-CBT timeframe exceptions

Child is emotionally unstable and needs

many sessions to learn to tolerate

trauma-related feelings

Complex trauma case

Child has repeated crisis situations

during therapy which prolongs the

course of tx

Child has prominent dissociation

symptoms

Childs living situation is still unsafe

TF-CBT adaptations
TF-CBT can be used with children with

special needs or developmental delays

TF-CBT can be used with children from a

variety of cultural backgrounds:

Adaptation for Latino families

Adaptation for Native American families

TF-CBT can be used in residential

treatment settings and/or situations where

no caregiver is present

Difficulties Addressed by
TF-CBT
CRAFTS

Cognitive Problems
Relationship Problems
Affective Problems
Family Problems
Traumatic Behavior Problems
Somatic Problems

Core Values of TF-CBT

CRAFTS

Components-Based

Respectful of Cultural Values

Adaptable and Flexible

Family Focused

Therapeutic Relationship Central

Self-Efficacy is emphasized

TF-CBT Assessment
Trauma Assessment

What is it?
In other words Why isnt the
DMH Intake Assessment enough?
How does this help my client?
How does this help me?

Impact of Trauma
Posttraumatic stress disorder
Depression
Substance abuse
Behavioral problems
Anxiety
Suicidal ideation
Nightmares, sleep problems
Academic difficulties
Poor peer relationships
Developmental Issues
Attachment problems

Trauma Assessment:
How is it Helpful?
DSM-V Diagnosis
Symptom Severity
Trauma Exposure
Developmental Issues
Simple vs. Complex Trauma
Inter-generational Issues
Culture, Religion, Strengths

Clinician Benefts
Identify high risk clients and salient symptoms
Help guide treatment planning and select

appropriate evidence-based interventions,

develop goals

Gather information not disclosed during an

interview

Confrm clinical observations and validate

need for treatment

Assess changes in symptoms over time

Identify systemic and family needs

Client Benefts of
Assessment
Helps clients see they are making progress,

or if not working- can reevaluate treatment

Helps clients identify difficult themes

(normalize that it happens to other children

and makes it easier to endorse)

Rapid Identifcation of Specifc Treatment

Issues

Confrm caregivers concerns and

observations

intense terror, horror

or helplessness

Subjective feeling of

bodily integrity

Death or threat to life,

such events

Shocking nature of

events

Sudden or unexpected

Traumatic Event

shooting

Death of loved one by

who was ailing

Death of grandmother

threatening illness

Medical trauma or life

Car accident

Divorce of Parents

Abuse, DV

Sexual Abuse, Physical

(earthquakes,
hurricanes)

Natural disasters

Examples: Yes or No?

 Past experiences

and perceptions

Trauma-related attributions

child, provided parents cope

well, likely wont cause
serious or lasting traumatic
symptoms. BUT, ongoing
traumas that start early in life
can alter childrens
development.

Short-lived trauma of young

risk?

Age protective or increased

(parental response)

External sources of support

Inherent or learned resiliency

Developmental level

Factors that Mediate

Response

 Trauma video

have higher resting pulse

rates and blood pressure,
greater physical tension
and hypervigilance.

Traumatized children may

psychobiological changes.
Neural pathways can be
altered: brain becomes
wired to expect danger.

There are also

behavioral, cognitive,
physical and/or emotional
difficulties directly related
to traumatic experience.

Trauma symptoms include:

Trauma Symptoms

the hallmark characteristic

of children and
adolescents with complex
trauma (Spinnazola et al.,
2005)

Emotional dysregulation is

sequential occurrence of
child maltreatmentincluding emotional abuse,
neglect, physical & sexual
abuse & DV (layers of
abuse)

Simultaneous or

chronic, interpersonal in
nature and begin at an
early age

Traumas are multiple,

1992

Term coined by Herman,

Complex Trauma

 Dissociation

Concept of self

Problems

Cognition & Attention

Behavior problems

Biology

Attachment

Affective regulation

Complex Trauma
(ABCDs) domains

 Vocational problems

Legal problems

Relationship issues

Self-harming behaviors

Depression and Anxiety

chronic medical illness)

Physical conditions (e.g.,

Addiction

Long Term Effects of

Complex Trauma

OR fashbacks and intrusive

thoughts as a result of trauma
and PTSD

True psychotic hallucinations

or delusions (psychiatric
referral)

4. Psychosis:

(may need to stabilize or

refer to other tx initially)

3. Serious substance abuse

or plans (may transiently

be worsened during TN)

2. Suicidal thoughts, intents

1. Self-report instruments

Assessment
Considerations

Long, pre-existing history (may need

to consider other tx frst)

Linked to trauma onset

To assess for general vocabulary and

feelings identifcation

To include thoughts and feelings

To assess ability to provide a

narrative with beginning, middle, end

Assess their level of support

History of own, independent traumas
Substance abuse
Availability to participate in treatment

7. Assessment of Parents

6. Neutral/baseline narrative

5. Behavioral Difficulties

Assessment
Considerations

emotional response

3. Managing caregivers own

2. Tolerating the childs affect

experience

1. Believing & Validating childs

responses (Cook et al., 2005)

3 main elements in caregivers

mitigates development of
PTSD symptoms and enhances
a childs tx outcome

Caregiver support strongly

Caregiver Support
Elements

 1992 Olympics in Barcelona

Parental Support

because they view chronic

trauma as normal fabric of life

May under-report experiences

give pertinent information at

intake (get from school, CSW,
etc.)

May not have a caregiver to

assessment as peeling an
onion; therapist should follow
pace of clients, obtaining what
information is available layer
by layer (Ford et al., 2005)

May need to conceptualize

(e.g., placement)

Assess secondary adversities

and distrust of others, clients

may be difficult to assess

Due to attachment problems

Assessment for Complex

Trauma

making progress, or if not

working can reevaluate
treatment

Helps clients see they are

and select appropriate

evidence-based interventions,
develop goals

Guides treatment planning

and observations

Confrm caregivers concerns

treatment issues (may not be

disclosed in regular intake)

Rapid identifcation of specifc

themes (normalize that it

happens to other children and
makes it easier to endorse)
and salient symptoms

Helps clients identify difficult

Benefts of Assessment

questions

Allow time for the client to ask

strengths

Reinforce child and parent

address difficulties presented

during assessment (behavioral
focus can help hook parents
into tx)

How will TF-CBT specifcally

experience, symptoms

Normalize and validate

level

Communicate Results at their

Engagement

Establish rapport-Family

Assessment Feedback

considerations: Rain Cloud

Likert Scale (Grosso, 2011).

Developmental

(YCPC): Scheeringa MS

Young Child PTSD Checklist

(CPSS): (Foa, Johnson, Feeny,

& Treadwell, 2001)

Child PTSD Symptom Scale

children (Briere & Elliot)

Trauma Symptom Checklist for

Inventory, Child Version

Traumatic Events Screening

(Pynoos, Steinberg)

UCLA PTSD Reaction Index

Assessment Measures

mother on drugs and

uninvolved in clients life

Father killed by gang violence,

family for entire life

(grandparent & other adult
relative); Primary language in
the home is Spanish

Living with relatives/other

adolescent from the

neighborhood resulting in
clients pregnancy

Sexual Assault by older male

receiving TF-CBT

13 year old, Latina female

Case Example - Ellen

Case Example: Ellen

Presenting Indicators of Severity of

Problems: Some academic and

behavioral problems at school; Some
difficulty with attachment/forming
relationships

Initial Clinical Evaluation: Post-traumatic

Stress Disorder, with possible rule-outs

for Traumatic Grief, Somatization,
Generalized Anxiety, Depression, Sleep
Disorder

GeneralTraumaInformation
Pleasecompletethefollowingbasedontheclientstraumahistory.Thisinformationshouldbemaintainedduringtreatmentiftraumaisexperiencedornewtraumaisrevealed.

Trauma Type

Has child
experienced
this trauma?
(Answer all Trauma
Types)

1. Sexual maltreatment/abuse:
(Actual
or attempted sexual molestation, exploitation, or
coercion by a caregiver)

(Actual or attempted infliction of physical pain

or bodily injury by a caregiver)

(Actual
or attempted infliction of physical pain or bodily
injury not by a caregiver and not recorded as
physical abuse )

(Emotional abuse, verbal abuse, excessive

demands, emotional neglect)

No
Yes
Suspected
2
1

(Physical, medical, or educational neglect)

No
Yes
Suspected
2
1

(Exposure to physical, sexual, and/or emotional

abuse directed at adult caregiver(s) in the home)

Unknown

No
Yes
1
Suspected
2
0

Unknown

No
Yes
Suspected
2
0
1

Unknown

No
Yes
Suspected
2
0
1

99

7. Domestic Violence:

Unknown

99

6. Neglect:

1
0

1
1

1
2

Unknown

99

5. Emotional abuse/Psychological
Maltreatment:

No
Yes
Suspected
2

99

4. Physical assault:

99

3. Physical maltreatment/abuse:

(Checkallagesthatapply)

99

2. Sexual assault/rape:
(Actual or
attempted sexual molestation, exploitation, or
coercion not by a caregiver and not recorded as
sexual abuse)

Whenwasthistypeoftraumaexperienced?
Ageinyears:

Unknown

No
Yes
Suspected
2
0
1

99

Unknown

1
3

1
4

1
5

1
6

1
7

Unknown
8

Trauma Detail, Sexual Maltreatment/Abuse

Complete the following if experience of this trauma type is indicated on the General Trauma Information Form.

1. When was this trauma revealed/known?

2.

3.

4.

Baseline
Other, please provide date: _02_/21/2008_

Please describe the frequency of the experience. (Check only one)

Please describe the type(s) of experience. (Check all that apply)

One-time event
Repeated exposure
2
Unknown
99
Experienced
Witnessed
Vicarious
Unknown
1

Please indicate the setting(s) of the experience. (Check all that apply)

5. Please identify the perpetrator(s). (Check all that apply)

6. Was serious injury inflicted?

Home
School
Community
Other, Specify: ____________________________
Unknown
Parent
Other adult relative
Unrelated (but identifiable) adult
Sibling
Other youth
Stranger
Unknown

No
Yes If YES, to whom: Child
1
(Check all that apply) Parent
Unknown
Other adult relative
99
Unrelated (but identifiable) adult
Sibling
Other youth
Other, Specify:_________
7. Was a report filed ? (e.g. Police, Child Protective Services)
No
0
Yes
1
Unknown
99
0

Salient Internalizing
Subscales: AT INTAKE:
Somatic Complaints (T=65;
93rd percentile; borderline);
Reduced to normal level by 6month follow-up (T=59; 81st
percentile)

T = 62
(Borderline)

T = 58 (Normal)

__________________________
Salient Externalizing
Subscales: AT INTAKE:
Social Problems (T=70; >97th
percentile; Clinical); Reduced
to borderline level by 6-month
follow-up (T=68; 97th
percentile)
__________________________
Overall Total Problems Score
reduced from Clinical level at
Intake to Borderline level at 6month follow up.

T = 56 (Normal)

T = 65; 93rd %ile

(Clinical)

T = 56 (Normal)

T = 61; 87th %ile

(Borderline)

UCLA PTSD Reaction Index: AT INTAKE

UCLA PTSD Reaction Index:

AT 6-MONTH FOLLOW UP

Index:
CHANGE OVER TIME

Trauma Symptom Checklist for ChildrenAlternate Version (TSCC-A) AT INTAKE

Trauma Symptom Checklist for ChildrenAlternate Version (TSCC-A) AT 6-MONTH

FOLLOW UP

Change over Time

Change over Time

PRACTICE Component

Psychoeducation and parenting skills

Relaxation
Affective expression and regulation
Cognitive coping & processing
Trauma narrative development &
processing
In vivo gradual exposure
Conjoint parent child sessions
Enhancing safety and future development

Psychoeducation key
elements
What is it? Defne
You are not alone Normalize (speak of

the unspeakable)
You are not crazy/strange (make sense of

the unexplainable)
It is not your fault
There is hope

Creative Psychoeducation
Interventions
Books: A Terrible Thing Happened, Brave Bart,

Ready to Remember (CTG), Please Tell (SA)

Games: What do you Know? Cards

Use of music, movies, videos, Halfofus.com
Jeopardy, Jenga
Cootie Catchers
DV cycle of violence wheel for kids
PTSD Video

Initiating Treatment with

Caregivers
Engagement is key: what will hook them
in?
Review assessment fndings
Encourage optimism, but predict possible
resistance or temporary exacerbation
of symptoms
Provide overview of treatment model
Establish time-frames
Highlight the caregiver role

TF-CBT Sessions Flow

Entire process is gradual exposure

Baseline
assessment

1/3

1/3

Sessions 1 - 4

Sessions 5 - 8

Psychoeducation
/Parenting Skills

Trauma Narrative
Development and
Processing

Relaxation
Affective
Expression and
Regulation
Cognitive Coping

In vivo Gradual
Exposure

1/3
Sessions 9 - 12
Conjoint Parent
Child Sessions
Enhancing Safety
and Future
Development

Parent Skills Training

Emphasize powerful parental infuence
in improving child behavior patterns
Observe parent-child dyad
Refocus parental attention on childs
strengths and encourage use of praise
Provide support for difficult child
behaviors parent is dealing with- hook
them into tx
Connect behaviors to trauma

Parenting Skills Training (contd)

Reasonable developmental expectations
Create or re-establish structure, rituals
and rules
Decrease negative attention to problem
behaviors (i.e. reduce yelling)
Utilize effective negative consequences
(e.g. time out, loss of privileges)
Create incentive plans

Praise
Praise a specifc behavior
Provide praise immediately after
behavior
Do not qualify your praise
Praise with much greater intensity and
frequency as compared to the intensity
and frequency of criticism
Catch your child being good
Offer global praise generously (i.e. I
love you)

Selective Attention
No reaction to certain negative behaviors
o
Defant or angry verbalizations to
parent
o
Nasty faces, rolling eyes, smirking
o
Mocking, mimicking
Walk away, busy oneself with an activity
Remain calm, unfazed
Expect a reaction of more provocative
behavior initially

Time Out
Purpose: Interrupt childs negative
behaviors and allow him/her to regain
control
2 kinds: automatic or warning
Location: quiet, least stimulating
Duration: 1 minute per year of age
Timer starts when child is calm
parent should refrain from comments
Variations: thinking time
Meeting on the Couch Playful Parenting

Contingency Reinforcement
Program
Purpose: Decrease unwanted
behaviors and increase desired
behaviors
Select only a few behaviors to target
Explain process to child
Involve child in decisions about
rewards
Add stars and give rewards weekly
Be consistent!

Themes & Barriers to

Parenting
Self-blame or blame towards child
Overprotective
Over permissive
Caregiver PTSD symptoms
Sees childs acting out as intentional
Concern about sexual acting out behaviors
Reinforcing regressive behaviors

Sexual behavior problems

Treat like any other behavior

problem

Develop understanding of behaviors (is it

to gain control, escape anxiety, get

attention)

Learn the patterns and triggers

Use verbal reminders and cues
Identify replacement behaviors & praise
Encourage continued use of appropriate

physical affection between parent-child

Sexual Reactivity Resources

http://nctsn.org/nctsn_assets/pdfs/

caring/sexualbehaviorproblems.pdf
Treatment Exercises for Child Abuse

Victims and Children with Sexual

Behavior Problems, Toni Cavanagh
Johnson, 2002.

PRACTICE Component

Psychoeducation and parenting skills

Relaxation
Affective expression and regulation
Cognitive coping & processing
Trauma narrative development &
processing
In vivo gradual exposure
Conjoint parent child sessions
Enhancing safety and future development

Relaxation Goals

Reduce physiological manifestations of

stress and arousal associated with trauma
reminders
Understand body response to stress
(shallow breath, muscle tension,
headaches)
Practice relaxation exercises during calm
states so that clients can easily apply them
when triggered, during in vivo work, or
when working on trauma narrative later in
treatment.

RELAXATION
Deep Breathing
Progressive Muscle Relaxation
Guided imagery exercises
Books, Music
Yoga, Meditation, Prayer
Grounding, mindfulness activities
Whatever works!

Relaxation Interventions
Toy soldier vs. Rag doll, Octopus vs.

Robot
Safe place activity
Relaxation Coloring Book
Relaxation basket
Bubbles, Hokey Pokey
Elmo Video
http://marc.ucla.edu/body.cfm?id=22

Relaxation
Vignettes small group exercise

PRACTICE Component

Psychoeducation and parenting skills

Relaxation
Affective expression and regulation
Cognitive coping & processing
Trauma narrative development &
processing
In vivo gradual exposure
Conjoint parent child sessions
Enhancing safety and future development

Rationale for Teaching Affect

Regulation Skills

Children often do not have the vocabulary

to express feeling types or intensity of
feelings
Children frequently rely heavily on their
avoidance as a way to cope
use of skills = effective expression and
management of feelings = need to use
avoidance strategies
Wound analogy, Bear & Thorn Story

Affect Regulation Goals

Label/defne feelings
Learn about connection w/ body
Express feelings safely
Understand causes/triggers
Assess intensity
GE: general feelings then trauma
related
Cope w/ feelings in adaptive way

Feelings Identifcation
Exercises
Feelings Brainstorm - Name as many
feeling words as you can in one minute
Games (Emotional Bingo; Talking, Feeling,
Doing Game; Mad, Sad, Glad game)
Heart Chart
Color Your Life Technique
Feelings Charades
Feelings Wheel

Affect Modulation
Interventions
SUDS Subjective Units of Distress Scale,

Feelings Thermometer
Art Therapy (masks)
Worry Wall (or Anger Wall)
Letter to the perpetrator
Bottling Anger, Volcano in my Tummy
Paper bag activity

Masks

Can by used to represent

what they feel in the inside

vs. what they show on the
outside

Before and After the

trauma

My
Feelings
Thermometer

Feelings activities for

complex trauma
Mirroring & labeling facial expressions
Distraction: turn down the volume of difficult

emotional states
Mindfulness: learn to observe feelings w/out

having to react to them.

Perceptual bias modifcation strategies: pictures

& in vivo
Self-awareness skill-building: describe recent

negative social interaction

Coping Skills
Goals for children
o
o
o

Find adaptive ways to cope

Reduce anxiety
Help children to tolerate extremes of emotions

Goals for parents

o
o
o

Highlight importance of modeling healthy

coping
Enhance their ability to cope with stress from
the incident, and for the GE process
Prepare parents to help their children with
coping strategies at home and following
termination

Coping Skills Toolkit

Can make client coping card
Relaxation skills (one public and one

private)
Distraction techniques
Mindfulness activities or grounding skills
Thought stopping techniques
Create your own

Caution About Distraction

Skills
Many coping skills could be considered brief

distraction techniques

Listening to music
Calling or texting a friend
Playing video games

While we want to reinforce use of effective

skills, we also want to refrain from

reinforcing avoidance

Depending on how children use the skills,

may need to address overuse of distraction

Coping Skills
For Parents
o
o
o
o
o

Self-Soothing activities
Positive Self-Talk
Exercise
Prescribed worry time
Support system

More About Coping for Parents

Parents may use session with therapists to

vent about their own reactions to trauma

Parents learn appropriate ways of seeking
support without involving children directly
Therapists teach coping to parents and
encourage them to prompt child at home
Therapists use collateral sessions to give
parents a jump start on cognitive
restructuring

PRACTICE Component

Psychoeducation and parenting skills

Relaxation
Affective expression and regulation
Cognitive coping & processing
Trauma narrative development &
processing
In vivo gradual exposure
Conjoint parent child sessions
Enhancing safety and future development

Cognitive Coping Goals

Help children distinguish between

thoughts, feelings & behaviors

Help children and parents

understand connections between

thoughts, feelings & behaviors
Help child/parent cope and improve

functioning when overwhelmed w/

trauma reminders & thoughts

Cognitive Coping
Learning to be in control of
your own mind, instead of
letting your mind be in
control of you (Linehan,
1993)

The Cognitive Triangle

Thoughts

Cognitive Triangle

Feelings

Behavior

The Cognitive Triangle

Identify neutral or non-abuse situation

(i.e., client who received an F in

science)
Initial thoughts: Im stupid, Ill never

graduate
Initial feelings: hopeless, self-defeated,

depressed
Behaviors: giving up, focusing on other

aspects of school

The Cognitive Triangle

continued
Alternative thoughts: I need more help in

Science because its not my best subject,

I have had trouble focusing due to the
trauma.
Connected feelings to alternative

thoughts: more hopeful, less self-blame.

Likely alternative actions: get a tutor, ask

teacher for additional assistance or extra

credit opportunities.

Cognitive Component - GE
This is one exception- children are not

asked about their trauma-related

cognitions until after their TN
May discourage child from sharing parts

of their experience social desirability

May alter trauma narrative
If it comes up, dont be too quick to

restructure

What Can I do Instead?

Listen, refect & validate
Ask what child has heard from others
Review what was learned in

psychoeducation

Review cognitive coping strategies

Tell child you are going to write this down

and revisit later

Can examine trauma-related cognitions w/

parents in this stage

Cognitive Coping
Strategies
Remote control, Change the channel
Replacement positive thought or song, change

the tune

Fly away balloons

Different glasses
Stop sign visualization
Say: Go away or Stop it, Im safe now.
Write & wipe board
Engage in positive activity

Cognitive Component with

Young Children
Normalize that we all talk to ourselves

What thoughts did you tell yourself when you

woke up before you actually spoke to anyone?

What do you tell yourself when you make a

mistake?
Can use a neutral example: hearing a loud

branch hit the window

Explain that just because you think something

doesnt make it true

The more you try not to think about something

the more it pops into your head

Creative Cognitive exercises with

Children
Tape Triangle on foor & play musical

corners
Picture Cues (Heart, head, hands)
Thought, feeling, behavior Bags/Boxes
Problem solving baseball
Right address/wrong address
Boundin Video

Cognitive Processing
Goals
Identify maladaptive thoughts and beliefs

about why the traumatic event occurred and

the feelings that accompany them
Promote the notion that thoughts can be

changed
Replace distorted cognitions with more

accurate, realistic, or helpful ones

Develop optimal understanding of the trauma

within the context of the childs life

Cognitive Processing - Caregiver

Help parent(s) identify own cognitive distortions

My child will never recover from this.

Help parent challenge his/her own distortions and

replace them with more accurate, helpful

cognitions

Identify where you want the caregiver to get

(healthy perspective) and what questions can get

them there.

Questions as your bridge

Cognitive processing can be done with parents

early on, but should be done later in treatment

with children.

My fault child
was abused

Cry | Isolate

Sad | guilt

Perpetrator
tricked us all

Talk About It

Less guilt

Socratic Questioning for

parents
Is the thought______true? Always true? What evidence

supports this idea? Any times its not true?

Does thinking this lead to positive or negative emotions and

behaviors?

Does thinking this help you feel good about yourself?

Does thinking this help you in your relationships with friends

and family?

Does thinking this help you in your daily life?

Does thinking this help you accomplish your goals?
How would your child feel if she heard you saying that out

loud?
If your best friend had a child who experienced a similar

trauma, would you say to her what you are saying to yourself?

CBITS Hot Seat Activity

Other ways to think about it:

- Is there another way to look at this?

- Is there another reason why this would happen?
What will happen next:

- Even if this thought is true, whats the worst thing

that can happen?
- Even if this thought is true, whats the best thing that
can happen?
-What is the most likely thing to happen?

CBITS Hot Seat Activity

example

Negative thought:
- If I fall asleep, Ill have nightmares

Hot (helpful other thoughts) seat thoughts:

- I dont have nightmares every night, so I might
not have them tonight.
- Nightmares arent real, they cant hurt me.
- I need to get some sleep for school tomorrow,
even if it means I have nightmares.

Cognitive challenges:
Scenarios for small groups
When we fll our thoughts with
the right things, the wrong
ones have no room to enter.
Joyce Meyer

PRACTICE Component

Psychoeducation and parenting skills

Relaxation
Affective expression and regulation
Cognitive coping and processing
Trauma narrative development &
processing
In vivo gradual exposure
Conjoint parent child sessions
Enhancing safety and future development

Trauma Narrative
A form of gradual exposure therapy
Client can face fears in a safe, controlled

environment
Repeated exposure to trauma memories,

thoughts and feelings

Client can gain a sense of mastery and

control over the trauma

Tolerate trauma reminders w/out avoidance

 Personal example

helping retell (over and over)

the story of the painful or
frightening experience

Promote integration by

hemisphere into the picture so

the child can begin to make
sense of what happened

Parents can help bring the left

or generalized fears and

avoidance of reminders of the
event

Children may develop specifc

event, emotions and bodily

sensations food to the right
hemisphere of the brain

After a traumatic or scary

Name it to Tame it
(Siegel and Payne Bryson, 2011)

The Trauma Narrative in

a nutshell
At the clients pace
Get the general story
Re-work and prompt for thoughts and

associated affect
Impact of the event & meaning making
Telling the story parental inclusion

Trauma Narrative
Considerations
Age and developmental level of the child
Verbal, abstract reasoning, writing

abilities of child

Can assess with neutral narrative

What engages child
As long as children are facing their fears,

TN can take any form

Possible Forms of TN
Talk show format, videotaped
Picture book
Poem, song lyrics
Newspaper article
Collage
Play, puppet show
Sand tray representation

Possible Chapters
About me, general information
Non-abusive interactions w/ perpetrator
First or most recent episode of trauma
Other specifc episodes
Disclosure & investigation, medical exams,

foster home experience

Worst, most disturbing or embarrassing

detail

Organizing Trauma
Narrative
Can create Title Page, Table of Contents
Best not to interrupt 1st draft
Help client put in chronological order

(Trauma Timeline, index cards)

If multiple episodes or traumas, ensure

that child writes about the worst.

Re-read what they have done prior to

each session for GE

More detail
What happened just before/after/next?
Prompt for thoughts, feelings (What were

you telling yourself when.?)

Prompt for sensory details (Time of day,

smells, sights, what child was wearing)

Ask questions to fll in the blanks
What is one thing you could add to your TN

that you havent told anyone else?

Meaning-Making
Re-telling the traumatic event in small

doses in a safe, controlled environment

Linking trauma events and current

reactivity

Refect on impact of the event(s)

Identify & challenge maladaptive beliefs
Develop a future orientation

Final Chapter
What have you learned?
What would you tell other kids who

experienced this?

How are you different now from when the

abuse/trauma happened?

How are you different from when you

started treatment?

Future goals

When to hold off on TN

Immediate safety concerns (i.e., client

suicidal or homicidal)
Stability signifcantly compromised-

imminent disruption in living environment

or treatment ending within next 2-4
weeks.
Substance abuse
Concept of stably unstable

TN for Ongoing Trauma

Focus early on enhancing safety
Create coherent memories with more

adaptive cognitions
Distinguish between real danger and

generalized trauma reminders

Enhance caregivers understanding of

childs trauma experiences and support

of child (engagement important)

Troubleshooting,
Resistance
Bibliotherapy
Revisit earlier components, cognitive triangle
Structure session to include focused work on

narrative and fun activity after

Small incentives
One more detail and were done for today
Work through the hot spot
If you delay the TN, you are delaying progress
20 ways to get started

Cognitive Processing
of the Trauma
Thought Classifcations

Inaccurate thoughts (i.e., The

sexual abuse was my fault.)
Accurate but unhelpful thoughts
(i.e., You can never tell when a driveby shooter might might hit you)
Inaccurate AND unhelpful thoughts
(i.e., Its my fault my dad hurt my
mom. I should have protected her.)

Cognitive Processing
of the Trauma
3 Common thinking errors (3 Ps)

Too Personalized (i.e., It's my fault my

child was abused or I should have known
better than to have trusted him)
Pervasive (i.e., The world is not safe or
I cant trust anyone)
Permanent (i.e., My family will never be
happy again or My child will never
recover from this)

Ways to Identify
Cognitive
Distortions
Assessment Measures
Cognitive Triangle
Responsibility Pie
Trauma Narrative
Parents perspective
Childs responses in role plays,

puppet shows, etc.

Worry Brain

Techniques for Challenging

Cognitive Distortions
Psychoeducation: corrective information
Examine the evidence and generate

alternative cognitions
The Best Friend role play
You be the Therapist role play
Encourage experiments
Progressive logical or Socratic questioning
Differentiate responsibility vs. regret

Developmental Considerations
for Cognitive Processing
For young children

Thought bubbles
Healthy eating analogy
Fill in the blank: I think this happened
because
Books: Tiger, Tiger, is it True? Little
Engine that Could
Picture cards

Cultural/Religious
Considerations
Explore possible culturally-related or

religious beliefs/distortions
Focus on healthy and helpful aspects

of cultural values vs.

unhealthy/unhelpful aspects
Use progressive logical questioning

and reframing
Spiritual leader participation

Cultural consideration
examples
Patriarchal father (in my country, father is the

boss= right to engage in DV)

Latino culture rape victim: having sex before

marriage= impure, loss of virginity. Implications

for Quinceaera, womanhood & marriage
Machismo: Difficulty of male sexual abuse

victims discussing their victimization or related

feelings that might make them seem weak.
Marianismo: suffer & endure attitude

Lets Practice
Dear Dad,
I will never get over what you did to me. It
hurt me that you thought I was nothing but a
piece of garbage. Now everyone knows what
happened to me. Although you called me a
liar in court I know I told the truth. I will never
know whether you forgive me for testifying. I
know you will pay for this because we have
both sinned.
The daughter you hate

What are some cognitive

distortions you see in this

letter?
How would you challenge

these distortions with the

client?

PRACTICE Component

Psychoeducation and parenting skills

Relaxation
Affective expression and regulation
Cognitive coping and processing
Trauma narrative development &
processing
In vivo gradual exposure
Conjoint parent child sessions
Enhancing safety and future development

Generalized Avoidance
Related to Trauma
Trauma Narrative is one way of helping

child master traumatic memories

Some kids continue to suffer from

generalized avoidant behaviors related to

the trauma: avoiding places, people, or
things that remind child of trauma (i.e.
school refusal, fear of bathrooms)

Avoidance interferes with childs

functioning and healthy adaptation

Example of sexual abuse case

In Vivo Considerations
Trauma cues are inherently innocuous

reminders of past trauma that dont serve a

purpose vs. cues that present situation is unsafe

Avoidance is a powerful self-reinforcer: child

comes to believe that avoidance is only way of

coping with fear

Child must be gradually exposed to feared

situation to overcome it

For younger children, use of transitional

objects, rituals, and imagination!

In Vivo Mastery of Trauma

Reminders
Behavioral plan to overcome avoidance

and cope with trauma triggers

Steps:

Identify and assess the feared

situation/triggers
Engage parent and child in creating
specifc desensitization plan to gradually
approach feared situation (SUDS scale)
Praise and reinforce in vivo work

In Vivo Mastery of Trauma

Reminders (continued)
Goal: improved adaptive functioning for

child and child regains sense of

competence and mastery
Ensure parent is committed to follow

through with plan; parent uses praise,

selective attention, and rewards
Make sure that each step of plan is

tolerable for child and parent

Therapist MUST have confdence that this

will work or it wont

In Vivo Role Play Activity

See Handout

PRACTICE Component

Psychoeducation and parenting skills

Relaxation
Affective expression and regulation
Cognitive coping and processing
Trauma narrative development &
processing
In vivo gradual exposure
Conjoint parent child sessions
Enhancing safety and future
development

Conjoint Parent Child

Sessions

Individual Child Sessions

Parents Sessions

Conjoint Parent-Child Sessions

Conjoint Parent Child Sessions

Evaluate childrens and parents readiness to

participate in joint sessions

Help parents to develop skills for responding

appropriately when children discuss traumatic

events

Promote positive, healthy communication

between parents and children about trauma

Train parents and children to continue

therapeutic work at home, even after

treatment ends

Goals for Sharing

Narrative
Resolve avoidance, shame, negative

cognitions, or other maladaptive

responses

Allow child to become more comfortable

in discussing thoughts and feelings with

parent even when upsetting

Parent should be the one that the child

can come to with any worries in the

future.

Conjoint Parent Child Sessions

1. Prepare the parent: therapist reads

narrative w/out client present frst, more

than once if needed, can video child

2. Can have parent prepare and practice

response, role play

3. Can have both client and parent think of

questions they want to ask

4. Prepare the child: dress rehearsal

5. Avoid surprises!

Conjoint work considerations

Predict some resistance
Ask parent to let therapist know if childs

symptoms increase
Ask parent to describe their experience

of the trauma apart from childs version

Majority of families say that creation of

the TN was the most helpful part of

treatment

Troubleshooting
What do you do if there is no caregiver to

share the narrative with?

What if parent continues to be in denial

or not appropriately supportive?

What if you encounter resistance from

the child?
Can always stop session if it goes awry

PRACTICE Component

Psychoeducation and parenting skills

Relaxation
Affective expression and regulation
Cognitive coping and processing
Trauma narrative development &
processing
In vivo gradual exposure
Conjoint parent child sessions
Enhancing safety and future development

Enhancing Safety
and Social Skills
Discussion of boundaries
Identifcation of Communication/Assertion

Skills
Role playing
Use new situations to assess understanding
Practicing implementation of healthy coping

skills and strategies

Enhancing Safety
and Social Skills
Review Sexual Abuse Safety even with cases

that do not involve sexual abuse

My Body Belongs to Me video

Confict resolution skills & Safety Planning for DV

cases or community violence

Boundary and Assertion Skills (bullying)

Evaluate and Increase Support System

Where to turn grid

WHERE TO TURN

SITUATION

Friend

Parent

School
Couselor

Teacher

School
Nurse

Church

Doctor

Principal

Relative

Therapy

AA Alateen

Other

Sexual abuse by stepdad

2 Physical abuse by mom

3 Parent uses drugs & alcohol

Friend tells you she's being

abused

5 Classmate hits you at school

6 Friend offers you drugs

7 Domestic Violence

TF-CBT with
Developmental Disabilities
Visual Cues for assessment & trauma

identifcation (can draw a mountain with the top

being the event that bothers me the most.)
A doll or picture of a person can be used to have

children point to areas that have tension/feelings

Soothing Toolkit, Coping Card, Photo Feelings

Cards, Bubble People instead of cognitive triangle

Index cards for narrative, story boards
Fixations & special interests

TF-CBT with Complex

Trauma
Adjust proportionality, half of sessions needed for

coping skills and regulation

Treatment length longer
Can help child fnd unifying theme(s) and integrate

traumas
GE to trusting relationships; caregiver involvement?
Blunted affect: previously punished, ridiculed and/or

dangerous to express feelings

May help to limit number of sessions on TN

Possible Complex Trauma

Themes
Blame & shame, betrayal, being damaged

People who should keep me safe hurt me.

Its hard to trust people when they always
leave.
How can I feel safe when people in my
family hurt each other?
No one will ever love me, my own parents
didnt.

Traumatic Grief
Do neutral or positive memories of the deceased

segue into traumatic memories or thoughts?

Grief components after processing trauma (PTSD

symptoms interfere w/ normal grieving process)

Interrupts developmental tasks or usual

activities (i.e., avoids baseball because father

not there to watch)
Contextualize trauma: how is client stronger or

moving forward

Bereavement Tasks
Psychoeducation: communicating about death
Mourning the loss; ambivalent feelings (letter)
Preserving positive memories (scrapbook, alter)
Redefning the relationship (convert from one of

interaction to one of memory)

Recommitting to new relationships
Making meaning of the death (help others)

Cognitive processing of
loss
Explore thoughts & feelings related to the

intentionality or fairness of act (i.e., if

homicide or sudden death)

Normalize thoughts, but emphasize that

no one can change the past

Focus on how we can change things in

the present and future by our own actions

We can change our own thoughts,

feelings & behaviors (cognitive triangle)

Future functioning
Assess for rescue or revenge fantasies

(If you had special powers and could

have made things turn out differently,
what would you have said or done to
change what happened?)
How can child achieve symbolic

corrective action? (i.e., letter to

deceased, gang prevention cause, MADD)

Future functioning 3 Ps
Predicting: client will experience painful

reminders in the future

Planning: address how client can cope

with reminders in the future

Permission: give permission to self and

others to have difficulties

* Termination: relationships can come and
go in their lives, not the same as
someone dying

Fidelity vs. Flexibility

Find a balance
Use all components, techniques can differ
Generally use in PRACTICE order, but can

vary as clinically appropriate

Use in reasonable amount of time

Fidelity checklists
Recipe analogy

Ending Treatment
Are trauma symptoms extinguished or

greatly reduced?
Can parent manage childs behavior and

any remaining symptoms?

Has child-parent communication

improved?
Treatment graduation: certifcate of

completion, celebration

Requirements for TF-CBT

Web-based training
2-Day basic training w/ national trainer
Track fdelity to the model with PRACTICE

checklist
Track symptoms w/ outcome measures
Completion of 3 cases
Consultations with a national trainer (12)
On-line test & licensed in state of practice

http://etl2.library.musc.edu
/tf-cbt-consult/